Transapical and Transfemoral Aortic Valve Implantation. Impact and General Considerations of both Approaches

espanolIntroduccion: El implante valvular aortico percutaneo (TAVI) ha surgido como una alternativa terapeutica en pacientes con estenosis aortica grave sintomatica inoperables o de elevado riesgo quirurgico. El acceso transapical surge como alternativa para aquellos pacientes con contraindicacion de implante valvular aortico percutaneo transfemoral. Objetivo: Valorar la factibilidad y la reproducibilidad del implante valvular aortico percutaneo transapical en nuestro centro y comparar la evolucion a corto y mediano plazo con los pacientes sometidos a implante valvular aortico percutaneo transfeoral. Material y metodos: Se evaluo una cohorte retrospectiva de 80 pacientes tratados con implante valvular aortico percutaneo transapical (n = 24) y transfemoral (n = 56) en nuestro centro. Se compararon las complicaciones relacionadas con el procedimiento segun las definiciones VARC-2, y se analizo la mortalidad a corto y mediano plazo entre ambos grupos. Resultados: Los pacientes del grupo transapical eran mas anosos (83,6 ± 5 versus 80,0 ± 8,3; p = 0,04); presentaron mayor prevalencia de coronariopatia (el 75% versus el 44%; p = 0,04) y mayor prevalencia de vasculopatia periferica (el 37% versus el 16%; p = 0,01). El grupo transapical tuvo menor exposicion a rayos X, (tiempo de fluoroscopia de 14,9 minutos ± 5,8 versus 22,9 minutos ± 8,7; p = 0,001); y una mayor tendencia a requerir dialisis luego del procedimiento (el 12,5% versus 1,8%, p = 0,13). El grupo transapical permanecio mas tiempo internado (13,6 ± 23 dias versus 7,2 ± 6,9 dias, p = 0,05). La mortalidad a 30 dias fue mayor en el grupo transapical (el 20,8% versus el 5,4%; p = 0,03) y al ano (el 25% versus el 8,9%; p = 0,04). Conclusiones: En nuestra experiencia, el implante valvular aortico percutaneo transapical es factible y puede ser realizado como un procedimiento reproducible para pacientes no aptos para el implante valvular aortico percutaneo transfemoral. El acceso transapical se asocio con mayor mortalidad durante el seguimiento, particularmente en el periodo posoperatorio a 30 dias, lo que coincide con varios reportes publicados. EnglishBackground: Transcatheter aortic valve implantation (TAVI) has emerged as a therapeutic option in inoperable or high surgical risk patients with severe symptomatic aortic stenosis. The transapical approach is an alternative access for patients with contraindications for the transfemoral access. Objective: The aim of this study was to evaluate the feasibility and reproducibility of transapical TAVI and compare the short and mid-term outcome with that of transfemoral TAVI. Methods: A cohort of 80 patients undergoing transapical (n=24) and transfemoral (n=56) TAVI was retrospectively evaluated. Procedure-related complications as defined by VARC-2 criteria, and short-term and mid-term mortality were analyzed and compared in both groups. Results: Patients in the transapical group were older (83.6 ± 5 vs. 80.0 ± 8.3; p = 0.04) and had greater prevalence of coronary artery disease (75 vs. 44%; p = 0.04) and peripheral vascular disease (37% vs. 16%; p = 0.01). Patients in the transapical group had lower fluoroscopy time (14.9 minutes ± 5.8 vs. 22.9 minutes ± 8.7; p = 0.001) and presented a non-significant trend toward greater requirement of dialysis after the procedure (12.5% vs. 1.8%, p = 0.13). Hospital stay was longer in the transapical group (13.6 ± 23 days vs. 7-2 ± 6.9 days, p = 0.05). Mortality at 30 days and one year was greater in the transapical group (20.8% vs. 5.4%; p = 0.03 and 25% vs. 8.9%; p = 0.04), respectively. Conclusions: In our experience, transapical TAVI is a feasible and reproducible procedure for patients with severe symptomatic aortic stenosis unsuitable for transfemoral approach. Transapical access was associated with increased risk of mortality at 30 days, in agreement with several publications.